Parties involved

Complaint

On 27 April 2001 the Commissioner
received a complaint from Mrs A about the treatment received by her
son, Mr B, from Dr C. The complaint was that:

On 25 January 2001, at a public hospital, Dr C failed to x-ray
Mr B's left shin laceration. In failing to perform an x-ray Dr C
missed a glass fragment, and failed to ascertain that Mr B's tendon
was damaged.

An investigation was commenced on 6
July 2001.

Information reviewed

Relevant medical records from the public hospital

Relevant medical records from a private radiology centre

Guidelines on Wounds and Lacerations in General used in the
Accident and Emergency Department at the public hospital.

Information gathered during investigation

On 25 January 2001 Mr B was involved
in an accident where a thick sheet of glass, which he had been
carrying with another person, was dropped and cut into his lower
left leg. Mr B advised that the sheet of glass had cut through his
leg, hitting the bone.

Mr B drove himself to the Accident
and Emergency Service at the hospital that same day. He was
attended by Dr C, a senior house officer in the Emergency
Department. Two student doctors were also present during the
examination.

Dr C advises that on examination he
found:

"a large flap laceration (base
distally) of the left leg at the level of the middle to distal
third pre tibial region. The skin of the flap was cut, slightly
obliquely on the medial border. The laceration extended through
skin, sub-cutaneous fat and part of the anterior tibia was exposed.
There was no detectable tendon or glass. Distally I found strong
dorsiflexion of the ankle and toes against resistance. There was no
sensory deficit and intact peripheral pulses."

In terms of the treatment provided
that day, Dr C confirms that he:

" ... cleansed the wound with
chlorhexidine, applied five vertical mattress sutures of 3/0
ethilon to the medial edge, which I found hard to appose due to the
oblique nature of the flap. The remainder was sutured with six 3/0
vicryl rapide internally and eleven interrupted 3/0 ethilon."

Dr C also states that he advised Mr
B to rest and keep his leg elevated for a few days. Mr B was
prescribed a course of Augmentin and codeine, and then discharged
that same day.

X-ray for glass
fragments

No x-ray was taken while Mr B was in
the Emergency Department to ascertain whether any glass fragments
were lodged in the wound.

There are differing accounts as to
why no x-ray was taken.

Dr C states that he advised Mr B
that "an x-ray must be performed of the area to check for any glass
fragments". Dr C's accounts of Mr B's response to this advice
differ. When the issue of failing to perform an x-ray was first
raised to the hospital by Mr B's mother, Dr C stated in his letter
of response:

"[Mr B] was adamant that the glass
could not have broken, that there was no possibility of a glass
chip being in the wound and declined the x-ray."

In Dr C's response to me, however,
he recalls Mr B's response as being a:

" ... confident insistence that the
pane of glass was thick and as I have documented in my clinical
notes, he was adamant that the glass could not have broken, that
there was no possibility of a chip".

Dr C does not state, in his response
to me, that Mr B refused to have an x-ray.

Dr C's clinical notes also make no
note of Mr B refusing to have an x-ray. They state:

"[Mr B was] Adamant that the glass
could not have broken - No possibility of chip."

Dr C admits, in his response to me,
that he was "reassured" by Mr B's insistence that the pane of glass
was thick and did not break. He states:

"In fact in over a year and a half
working in emergency medicine this has been the only laceration
resulting from glass that I have not x-rayed. I unfortunately was
reassured by [Mr B's] insistence that the pane was thick and did
not break. I remember his response to my decision to x-ray the
wound, which was to the affect of 'there's no need for that'. On
reflection I could have insisted on an x-ray, however the patient
had convinced me that [the] glass was intact."

Mr B advises that he did not refuse
an x-ray at any time. While Mr B accepts that he did tell Dr C the
glass was thick and was unlikely to have broken, he denies ever
refusing an x-ray. Given Dr C's clinical notes and inconsistent
statements, I accept that Mr B did not refuse an x-ray that
day.

In terms of the advice given with
regard to the consequences of not having an x-ray, Mr B states that
Dr C did not advise him of such consequences. Dr C disputes this,
noting that he "did consider or indeed inform [Mr B] of the need to
x-ray, however he reassured me that the glass did not break".

Tendon damage

During the course of the examination
on 25 January 2001, Dr C also examined Mr B for tendon damage. Dr
C's clinical notes state:

" ... carefully checked the relevant
muscle groups of that area and found no deficit ... I feel I could
not have taken any further measures to determine tendon
injury."

As a result of the examination, Dr C
concluded that there had been no tendon damage and therefore did
not request an ultrasound or MRI scan.

Mr B confirms that Dr C had advised
him that there was no tendon damage. He states that Dr C had
commented that Mr B was lucky the wound was at the front of his leg
rather than the back.

Subsequent
treatment

Mrs A (Mr B's mother) advised that
Mr B could not "weightbear" on his leg, nor put his foot on the
ground, following the accident. His condition was such that they
had to hire crutches for him. She also stated that after the course
of antibiotics was finished, the wound was still inflamed, tender
and swollen.

On 28 March 2001 Mr B sought the
assistance of a general practitioner.

On 29 March 2001 an x-ray and
ultrasound were taken of Mr B's leg. The x-ray revealed that a
glass fragment was lodged in the wound.

The ultrasound confirmed that the
"tibialis anterior tendon was ruptured". It showed that there were
"bunched up fibres of the tibialis anterior tendon at the proximal
musculo-tendon junction".

On 30 March 2001 Mrs A, on behalf of
her son, wrote to the hospital to complain about the treatment
received.

The Clinical Director of Emergency
Services, confirmed in his response to Mrs A that it was
departmental policy to x-ray a wound where it is suspected that
glass could be present.

The Clinical Director later provided
a copy of the Department's guidelines and protocols for wound
management. The "Guideline on Wounds and Lacerations in General"
specifically states that "wounds caused by glass must be
x-rayed".

Independent advice to Commissioner

The following independent expert
advice was obtained from Dr Peter Freeman, a specialist in the
field of emergency medicine:

"On 25th January 2001, at [the]
hospital, [Dr C] failed to x-ray [Mr B's] left shin laceration. In
failing to perform an x-ray [Dr C] missed a glass fragment, and
failed to ascertain that [Mr B's] tendon was damaged.

What specific professional
and other relevant standards apply in this case and did [Dr C] meet
those standards?

The right to appropriate standards
of service was not met. The guidelines on Wound and Lacerations in
General were not followed (yellow tag 1).

Should all glass lacerations
be x-rayed? Does tendon damage show up on x-ray?

Wounds caused by glass must be
X-rayed. Tendon damage does not show up on X-ray. Ultrasound or MRI
is required to image soft tissue defects.

In your opinion were [Dr
C's] reasons for not x-raying [Mr B's] laceration on 25/01/2001,
reasonable in the circumstances?

It can be difficult if the patient
feels the likelihood of glass in the wound is minimal. [Dr C]
documented 'Adamant that the glass could not have broken - No
possibility of chip' (Yellow tag 2). However it would have been
more appropriate to document advice for X-ray. [Dr C] should have
insisted on an X-ray and it was not reasonable to be persuaded
otherwise.

Was the examination [Dr C]
performed appropriate to check for tendon damage? If not what
further tests should have been performed?

[Dr C] describes 'Distally - full
dorsiflexion ankle/foot against resistance. Toes full dorsiflexion
against resistance' (Yellow tag 3). This demonstrates appropriate
examination for functional deficit. Partial tendon damage can occur
with apparent normal function. The muscles of the anterior
compartment of the lower leg are: Tibialis Anterior, Extensor
digitorum longus, Extensor hallucis longus and fibularis tertius.
Of these muscles the Tibialis Anterior muscle is the main
dorsiflexor of the ankle joint although the others do contribute to
dorsiflexion to a lessor degree.

What is a flap
laceration?

A flap laceration is a skin defect
where the line of incision into the tissues is oblique such that a
skin and soft tissues flap is created. This has relevance to wound
healing because the flap may not have as good a blood supply as the
surrounding tissues - particularly when the flap is 'distally
based'.

Are pre-tibial lacerations
difficult to treat? If yes, why?

Yes. Pre-tibial lacerations are
notorious for poor healing and consideration must be given to
maximise healing potential. The blood supply in this area is poor
and the wound is often a flap laceration.

Any other issues raised by
the supporting documentation?

The glass foreign body found later
on X-ray was 10mm which would have been visible had an X-ray been
taken on 25th Jan 2001. It would have been advisable to explore the
wound in order to remove this glass foreign body as it is
recognised that wounds heal poorly if there is a foreign body
present. The poor healing of the wound in question is likely to
have been partially a result of the 10mm glass fragment left in the
wound and partly due to location and configuration."

Further clarification was sought
from Dr Peter Freeman with regard to Dr C's examination for tendon
damage. Dr Freeman was asked to clarify whether an ultrasound or
MRI should have been requested, or whether the physical examination
performed by Dr C was sufficient in the circumstances. The
following is Dr Freeman's advice:

"I would confirm that I would regard
[Dr C's] examination as being sufficient in eliciting tendon
damage. This would be the generally accepted standard of care in
the assessment of a patient with suspected soft tissue injury. My
comment 'ultrasound or MRI is required to image soft tissue
defects' refers to the imaging modalities available to demonstrate
soft tissue defects. It was in fact ultrasound that eventually
demonstrated division of the tibialis anterior tendon. This however
would not be considered as a first line investigation in an injury
of this nature unless the clinical suspicion was great enough to
warrant further investigation. In the case in question [Dr C]
satisfied himself clinically that there was no tendon injury and I
would accept this as an appropriate check for tendon damage.

Therefore either the tendon was only
partially divided and subsequently ruptured or [Dr C's] examination
was incorrect. I feel it is appropriate to give [Dr C] the benefit
of the doubt for his examination and as the tendon was subsequently
found to have divided it must be assumed that a partial tendon
injury became a complete tendon injury at some time after [Dr C's]
examination."

Dr C is no longer resident in New
Zealand.

Code of Health and Disability Services Consumers'
Rights

The following Rights in the Code of
Health and Disability Services Consumers' Rights are applicable to
this complaint:

RIGHT 4

Right to Services of an
Appropriate Standard

1) Every consumer has the right to
have services provided with reasonable care and skill.

2) Every consumer has the right to
have services provided that comply with legal, professional,
ethical, and other relevant standards.

Opinion: Breach - Dr C

Right 4(2)

Failure to comply with professional
and other standards

In my opinion Dr C breached Right
4(2) of the Code of Health and Disability Services Consumers'
Rights in the course of providing medical services to Mr B.

Right 4(2) states that every
consumer has the right to have services provided that comply with
"legal, professional, ethical, and other relevant standards".

The hospital's "Guideline on Wound
and Lacerations in General" provided that "wounds caused by glass
must be x-rayed".

Dr C in his response to the
complaint confirmed that it is his ordinary practice to have wounds
x-rayed where glass is involved. In this instance, however, he
allowed himself to be influenced by Mr B's statement that the sheet
of glass was thick and had not broken.

I accept my expert advisor's advice
that Dr C should not have been persuaded by Mr B's statement that
the glass did not break.

It was Dr C's responsibility to
insist on an x-ray being taken, and to comply with the guideline.
The wording of the guideline is such that it is mandatory for an
x-ray to be taken, and does not allow for any discretion on the
part of the doctor. As Mr B had not refused an x-ray, but merely
queried the need for one, Dr C was bound to comply with the
guideline and ensure that an x-ray was taken.

I therefore find Dr C in breach of
Right 4(2).

Opinion: No breach - Dr C

Right 4(1)

Failure to provide services with
reasonable care and skill

In my opinion Dr C did not breach
Right 4(1) of the Code in failing to diagnose tendon damage.

Right 4(1) states that every
consumer has the right to have services provided with reasonable
care and skill.

There was nothing to indicate upon
Dr C's examination that there was tendon damage, or warrant the
taking of an ultrasound or MRI scan. It was therefore reasonable of
Dr C not to order an ultrasound or an MRI scan, or even an x-ray
since an x-ray will not show tendon damage.

As my expert advisor has noted,
partial tendon damage can occur with normal function. He further
notes that it is possible that the partial tendon damage did not
become a 'complete' tendon injury until after the examination; that
is to say, it ruptured at some point following the examination by
Dr C.

I therefore find that Dr C did not
breach Right 4(1) of the Code.

Opinion: No breach - The Public Hospital

Vicarious
liability

Employers are vicariously liable
under section 72(2) of the Health and Disability Commissioner Act
1994 for ensuring that employees comply with the Code of Health and
Disability Services Consumers' Rights. Under section 72(5) it is a
defence for an employing authority to prove that it took such steps
as were reasonably practicable to prevent the employee from doing
or omitting to do the thing that breached the Code.

The public hospital employed Dr C as
a senior house officer in the Emergency Department, and it was in
this capacity that he assessed and treated Mr B.

Dr C breached Right 4(2) of the Code
by not complying with the hospital's "Guideline on Wounds and
Lacerations in General". However, I consider this to have been a
clinical decision by an individual practitioner, and not a decision
that was attributable to, or reasonably preventable by, the public
hospital.

I am therefore of the opinion that
the public hospital did not breach Right 4(2) of the Code of Health
and Disability Services Consumers' Rights.

Actions

I recommend that Dr C review his
practice in light of this report.

Further actions

A copy of this opinion will be sent to the Medical Council of
New Zealand.

A copy of this opinion, with identifying features removed, will
be sent to the Australasian College for Emergency Medicine (New
Zealand Faculty), and placed on the Health and Disability
Commissioner website, www.hdc.org.nz, for educational
purposes.